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Kevin Seitz M.D., Robin Stiller M.D., Mark Zaros M.D., Andrew Hahn M.D.
University of Washington Department of Medicine, Harborview Medical Center

Case presentation:
A man in his 70s with atrial fibrillation on oral anticoagulation was brought in by EMS because of recurrent falls, accompanied by his wife. He had fallen three times in the last two weeks, striking his head each time. Regarding the fall on the day of admission, he described stumbling backwards, and he denied experiencing loss of consciousness or neurologic symptoms after this or any prior falls. His wife contributed that over the prior two days his mentation was slower, and he had been sleeping more than usual. He also reported experiencing a fever and dry cough for two weeks with associated intermittent low-grade fevers (100.5F), night sweats, and sore throat. He denied any dyspnea, rhinorrhea, or recent travel. On review of systems, he also acknowledged that his stools had been loose for five days.

Physical exam:
In the Emergency Department his vital signs were: T 37.2C, P 133, BP 104/81, RR 20, SpO2 95% on ambient air. He was in no acute distress with multiple ecchymoses on his forehead. On auscultation, he had coarse breath sounds and moderate wheezing bilaterally. His heart rate was irregularly irregular and his neurologic exam was normal.

Pertinent laboratory values:
On laboratory evaluation, his Creatinine was 1.91mg/dL from a baseline of 1.5mg/dL. His White-cell count was 7.3k/μl with 1.3k/μl Lymphocytes. Platelets were 160k/μl, and INR was 2.2. Troponin and all Liver Function Studies were within normal limits.

Pertinent imaging:
Computed tomography of his head and cervical spine demonstrated no acute traumatic injury but partial visualization of lungs showed an incidental finding of ground glass opacities in the right upper lung (image attached). Chest radiograph showed clear lung fields.

Treatment and outcomes:
Concern about his respiratory symptoms developed over his stay in the ED, prompting airborne isolation precautions, and an interview with his wife, who was also experiencing similar mild respiratory symptoms. She attributed these to working recently with a child who had been sick. Nasopharyngeal swabs were obtained from both the patient and his wife and were sent for COVID-19 and extended respiratory viral panel PCR testing. After clinical evaluation, she was discharged to home with viral tests pending.
The patient’s heart rate normalized after treatment with metoprolol, diltiazem, and 3L of crystalloid fluid. Too weak to stand unsupported, he was admitted to the ward and treated empirically with antibiotics for community acquired pneumonia. The following day, his cognition had improved, and Creatinine was at baseline. The novel coronavirus (SARS-CoV-2) PCR result was inconclusive (interpreted as positive), and the Extended Respiratory Viral Panel PCR was negative. Antibiotics were discontinued. He was able to ambulate independently and was discharged home with his wife, whose SARS-CoV-2 PCR test was positive. State laboratory confirmation of this testing is unavailable at this time.

Lessons learned:
This case illustrates community transmission of COVID-19 with an atypical presentation of mild disease. Respiratory symptoms were of less concern to the patient and his wife than his falls, reinforcing the importance of heightened vigilance among clinicians, and, in appropriate cases, opportunities for self-management in the outpatient setting.

*This case has been reviewed by a NEJM editor.*